Nursing 115 exam #3 review
The recommended antimicrobial agents for chemoprophylaxis or treatment of Whooping cough (Pertussis) are EXCEPT A. Nirmatrelvir with ritonavir (Paxlovid) B. Erythromycin (Erythrocin) C. Trimethoprim-sulfamethoxazole (Septra) D. Azithromycin (Zithromax Tri-Pak)
Answer A Paxlovid Option A: Pertussis is a highly contagious and serious infection that is caused by a bacterium so an antiviral agent (Amantadine) will not be effective. Option B & D: Macrolides such as erythromycin and azithromycin are the drug of choice for pertussis in children 1 month of age and older. Option C: Trimethoprim-sulfamethoxazole, an antibacterial sulfonamide is an alternative drug to macrolides for patients with pertussis ages 2 months and older.
A home health nurse is assessing a patient with advanced stage lung cancer. Upon assessing the patient, the nurse notices wheezing, bradycardia and a RR of 10 breaths/ min. These signs are associated with what condition? A. Hypoxia B. Delirium C. Hyperventilation D. Semiconsciousness
Answer A. As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.
The nurse is teaching a patient with emphysema how to perform pursed lip breathing. The patient asks the nurse to explain the importance of this breathing technique. Which is the best explanation to provide the patient? A. It helps prevent early airway collapse B. In increases inspiratory muscle strength C. It decreases use of accessory muscles D. It prolongs the inspiratory phase of respiration
Answer A. Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)
The nurse is assessing a client diagnosed with cellulitis of the upper left arm. Which manifestation should the nurse anticipate finding with this client? (Select all that apply.) A. Swollen lymph glands B. Pustules with surrounding erythema C. Deep, firm, painful nodule D. Fever and chills E. Erythema
Answer A. Swollen lymph glands D. Fever and chills E. Erythema
The air inspired and expired in each breath is called: A. Tidal volume B. Residual volume C. Vital Capacity D. Space Capacity
Answer A. Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways.
A patient with emphysema is prescribed oral prednisone to control inflammation. During patient teaching, the nurse explains the importance of taking the medication as prescribed and to not discontinue abruptly as this may cause: A. Hyperglycemia B. Acute adrenal insufficiency C. GI Bleed D. Seizures
Answer B. Administration of a corticosteroid such as prednisone suppresses the body's natural cortisol secretion, which may take weeks or months to normalize after drug discontinuation. Abruptly discontinuing such therapy may cause the serum cortisol level to drop low enough to trigger acute adrenocortical insufficiency. Hyperglycemia, glycosuria, GI bleeding, restlessness, and seizures are common adverse effects of corticosteroid therapy, not its sudden cessation
An infant who has clinical manifestations of AOM is brought to an outpatient facility by his parent. The nurse should recognize that which of the following factors places the infant at risk for otitis media? (Select all that apply.) A. Breastfeeding without formula supplementation. B. Attends day care 4 days per week. C. Immunizations are up to date. D. History of cleft palate repair. E. Parents smoke cigarettes outside.
Answer B. Attends day care 4 days per week. D. History of cleft palate repair. E. Parents smoke cigarettes outside.
A patient is admitted for influenza. The nurse monitors the client closely for complications. Which complication is most commonly associated with influenza? A. Septicemia B. Pneumonia C. Meningitis D. Pulmonary Edema
Answer B. Pneumonia is the most common complication of influenza. It may be either primary influenza viral pneumonia or pneumonia secondary to a bacterial infection. Other complications of influenza include myositis, exacerbation of chronic obstructive pulmonary disease, and Reye's syndrome. Myocarditis, pericarditis, transverse myelitis, and encephalitis are rare complications of influenza. Although septicemia may arise when any infection becomes overwhelming, it rarely results from influenza. Meningitis and pulmonary edema aren't associated with influenza.
An African American patient seeks care at the emergency department due to asthma attack in acute respiratory distress. Due to the patient's dark skin complexion, where is best to check for cyanosis? A. Lips B. Mucous membranes C. Nail beds D. Earlobes
Answer B. Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.
A patient with cystic fibrosis is admitted in the hospital for acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Immediately before a meal B. At least 2 hours after a meal C. When bronchospasm occurs D. When secretions have mobilized
Answer B. The nurse should perform chest physiotherapy at least 2 hours after a meal to reduce the risk of vomiting and aspiration. Performing it immediately before a meal may tire the client and impair the ability to eat. Percussion and vibration, components of chest physiotherapy, may worsen bronchospasms; therefore, the procedure is contraindicated in clients with bronchospasms. Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication for postural drainage, another component of chest physiotherapy.
A patient with COPD is recovering from a recent MI. Because the patient is weak and cannot produce an effective cough, the nurse should monitor the patient closely for: A. Pleural effusion B. Pulmonary edema C. Atelectasis D. Oxygen Toxicity
Answer C. In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
In COPD, which nursing action is best to promote adequate gas exchange? A. Encourage the patient to drink 3 glasses of fluid a day B. Keeping the patient in a semi-Fowler's position C. Using a high flow Venturi mask to deliver oxygen as prescribed D. Administer a sedative as prescribed
Answer C. The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in www.rn101.net www.rn101.net high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.
A patient is admitted for COPD. Which nursing diagnosis is most important for this patient? A. Activity intolerance related to fatigue B. Anxiety related to threat to health C. Risk for infection related to retained secretions D. Impaired gas exchange related to airflow obstruction
Answer D. A patent airway and an adequate breathing pattern are the top priority for any client, making impaired gas exchange related to airflow obstruction the most important nursing diagnosis. The other options also may apply to this client but are less important.
A clinical instructor is providing teachings among nursing students about the stages of pertussis. Which of the following is the final phase of a pertussis infection? A. Paroxysmal phase B. Recovery phase C. Catarrhal phase D. Convalescent phase
Answer D: The final phase of a pertussis infection is known as the convalescent phase. This usually lasts 2-6 weeks where coughing becomes milder and less frequent.
Which of the following statements are true about Pertussis? Select all that apply. A. Pertussis (Whooping cough) is caused by the bacteria Bordetella pertussis. B. Tdap, a combination vaccine given as a protection against tetanus, diphtheria and pertussis. C. Infected individuals are most contagious up to about 2 weeks after the cough begins. D. Infants under six months of age are require for home care monitoring. E. Early symptoms of the disease (runny nose, low-grade fever, and a mild, occasional cough) can last for 1 to 2 weeks.
Answer: A, B, C, and E. Option D: Infants under 6 months who are diagnosed with pertussis requires hospitalization to carefully observe and treat for possible respiratory complications such as apnea, cyanosis, or hypoxia.
A pregnant woman went to a community clinic to ask a health care provider about Dtap vaccination. Which of the following statements made by the HCP is true about the vaccine, except? A. After receiving a Tdap vaccine, the mother's body will create antibodies and passes some of them to the baby prior to birth. B. If Tdap is administered before pregnancy, it should not be repeated between 27 and 36 weeks gestation. C. A single dose of Tdap vaccine will provide enough protection on the succeeding pregnancy. D. All women can receive a Tdap vaccine during the 27th through the 36th week of pregnancy.
Answer: C. A single dose of Tdap vaccine will provide enough protection on the succeeding pregnancy. Option C: It is recommended to get a Tdap vaccine during each pregnancy since the amount of pertussis antibodies in the body decreases over time. Options A, B, and D: These are accurate statements about Tdap vaccine during pregnancy.
The nurse is teaching the client with diabetes mellitus about prevention of cellulitis. Which instruction should the nurse provide? (Select all that apply.) A. "Apply topical antibiotic to the wound daily." B. "Wear properly fitting shoes." C. "Keep wounds uncovered." D. "Keep wounds dry." E. "Wash the wound carefully with soap and water."
answer A. "Apply topical antibiotic to the wound daily." B. "Wear properly fitting shoes." E. "Wash the wound carefully with soap and water
The pediatric nurse is discussing with the parent the care of a toddler with multiple insect bites. Which information should the nurse include in the discussion to help prevent development of cellulitis? A. "Distract the toddler from scratching or picking at the wounds." B. "Make sure the toddler's hands are washed frequently." C. "Bathe the toddler daily using Epsom salts in the bath." D. "Administer antipyretics to help with discomfort."
answer A. "Distract the toddler from scratching or picking at the wounds."
A client is admitted with cellulitis. Which manifestation should the nurse monitor? (Select all that apply.) A. Fever B. Chills C. Itching D. Headache E. Malaise
answer A. Fever B. Chills D. Headache E. Malaise
The nurse is performing a health history for a new client in the clinic. Which should the nurse identify as a risk factor for cellulitis in an adult? (Select all that apply.) A. Peripheral vascular disease B. Hypertension C. Obesity D. Diabetes mellitus E. Impetigo
answer A. Peripheral vascular disease C. Obesity D. Diabetes mellitus
A client is diagnosed with methicillin resistant staphylococcus aureus pneumonia. What type of isolation is MOST appropriate for this client? a. Reverse isolation b. Respiratory isolation c. Standard precautions d. Contact isolation
answer Answer D. Contact or Body Substance Isolation (BSI) involves the use of barrier protection (e.g. gloves, mask, gown, or protective eyewear as appropriate) whenever direct contact with any body fluid is expected. When determining the type of isolation to use, one must consider the mode of transmission. The hands of personnel continues to be the principal mode of transmission for methicillin resistant staphylococcus aureus (MRSA). Because the organism is limited to the sputum in this example, precautions are taken if contact with the patient"s sputum is expected. A private room and BSI, along with good hand washing techniques, are the best defense against the spread of MRSA pneumonia
A 2 year old is to be admitted in the pediatric unit. He is diagnosed with febrile seizures. In preparing for his admission, which of the following is the most important nursing action? a. Order a stat admission CBC. b. Place a urine collection bag and specimen cup at the bedside. c. Place a cooling mattress on his bed. d. Pad the side rails of his bed.
answer Answer D. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. Preparing for routine laboratory studies is not as high a priority as preventing injury and promoting safety. A cooling blanket must be ordered by the physician and is usually not used unless other methods for the reduction of fever have not been successful. The child has a diagnosis of febrile seizures. Precautions to prevent injury and promote safety should take precedence.
The nurse is teaching a client with cellulitis about home care measures to increase comfort. Which instruction should the nurse provide? (Select all that apply.) A. "Apply ice packs to the affected area to reduce edema." B. "Apply sterile saline dressings to the affected area to promote drainage." C. "Keep the affected area below the level of the heart to promote circulation." D. "Wash hands thoroughly before touching the affected area." E. "Get enough rest."
answer B. "Apply sterile saline dressings to the affected area to promote drainage." D. "Wash hands thoroughly before touching the affected area." E. "Get enough rest."
A nurse is assessing an infant. Which of the following findings are clinical manifestations of acute otitis media? (Select all that apply.) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying
answer B. Rolling head side to side C. Loss of appetite E. Crying
The nurse collects a drainage sample to be cultured from the affected area of a client with cellulitis. Which organism should the nurse suspect is the most likely cause of the cellulitis? A. Escherichia coli B. Staphylococcus aureus C. Bacillus subtilis D. Group A Streptococcus
answer B. Staphylococcus aureus
A nurse is caring for a 2-year-old child who has had three ear infections in the past 5 months. The nurse should know that the child is at risk for developing which of the following as a long-term complication? A. Balace difficulties B. Prolonged hearing loss C. Speech delays D. Mastoiditis
answer C speech delays
The nurse is providing home care instruction to the client with cellulitis. Which statement, if made by the client, should concern the nurse? A. "I will keep all follow-up appointments with my healthcare provider." B. "I will be sure to get enough rest and stay off my affected leg." C. "I will take my antibiotics until the affected area looks less red." D. "I will keep my affected leg elevated to keep swelling down."
answer C. "I will take my antibiotics until the affected area looks less red.
The nurse is performing a health history on a client with cellulitis that developed from a hand wound. Which factor will help determine the organism responsible for the cellulitis? (Select all that apply.) A. Current medications B. History of cellulitis C. Cause of wound D. Wound exposure to contaminated water E. History of diabetes
answer C. Cause of wound D. Wound exposure to contaminated water
The nurse is caring for a toddler with acute otitis media. Which of the following is the priority action for the nurse to take? A. Provide emotional support for the family B. Educate patient on their diagnosis C. Stress importance of breastfeeding D. Administer analgesics
answer D administer analgesics
The nurse examines a wound on a client with a history of cellulitis. Which manifestation suggests cellulitis? A. Intact skin with nonblanchable redness and elevated borders B. Reddened skin with indistinct borders and covered by a yellow, fibrous film C. Pink or red skin with circumscribed regular borders D. Red or lilac edematous skin with a well-defined, nonelevated border
answer D. Red or lilac edematous skin with a well-defined, nonelevated border
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder: A: Alcoholism and hypertension B: Obesity and diabetes C: Stress-related illnesses D: Cardiopulmonary disease and lung cancer
answer D: Cardiopulmonary disease and lung cancer
A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A: Increased breathlessness but increased activity tolerance B: Decreased breathlessness and decreased activity tolerance C: Increased activity tolerance and decreased breathlessness D: Decreased activity tolerance and increased breathlessness
answer D: Decreased activity tolerance and increased breathlessness
